For decades, the fear of becoming impotent and incontinent as
a result of surgery for prostate cancer kept many men from undergoing
screening and treatment, leading to many deaths that might have
been prevented. This situation has changed drastically in recent
years, with the use of new surgical approaches to removing the
prostate that spare nerves and tissues in the area and can avoid
the dreaded side effects. In addition, many men once thought to
be "incurable" are now able to avoid surgery altogether
and live longer lives with more effective radiation therapy.
The two physicians who pioneered those treatments and were instrumental
in changing prostate cancer treatment--Dr. Patrick C. Walsh, director
of the Department of Urology at Johns Hopkins University, and
Dr. Malcolm A. Bagshaw, Professor Emeritus of Cancer Biology at
Stanford University--shared the 1996 Charles F. Kettering Prize
for outstanding contributions to the treatment of cancer, awarded
by the General Motors Cancer Research Foundation.
A Unique Route to Less Fearsome Surgery
In an era of "high-tech" medicine and imaging, it was
the old-fashioned learning tools of anatomic studies and cadaver
dissection that led to an new anatomic approach to radical retropubic
prostatectomy, which not only spares the nerves that supply the
penis but also can greatly reduce incontinence and severe intraoperative
In the 1970s, Dr. Patrick Walsh embarked on a series of anatomic
studies to delineate the structures surrounding the prostate,
in an effort to prevent these problems. Initially, he mapped the
anatomy of the dorsal vein complex around the prostate, and was
able to eliminate the severe bleeding that typically hampered
surgery. After noting that one of his patients was fully potent
after the improved surgery, Dr. Walsh set out to find out why
most men became impotent. By dissecting infant cadavers, in which
pelvic nerves and tissues are more clearly seen, he was able to
locate the nerves that supply the corpora cavernosa and give rise
to erections. "These nerves had never been charted. It was
assumed that these nerves ran through the prostate, but it turned
out that they ran outside the prostate," said Dr. Walsh.
By not cutting or only removing nerves on one side, he was able
to preserve potency.
In 1990, Dr. Walsh charted the anatomy of the striated sphincter
(which controls urine retention) and refined the surgery further
to avoid damage to the bladder neck and urethra, preventing incontinence.
"It is now possible to remove the prostate with excellent
tumor control and improve the quality of life in carefully selected
patients," he commented.
Dr. Walsh has made other important contributions to the field,
including the characterization of familial and genetic factors
responsible for prostate cancer. He has established the largest
registry of men with hereditary prostate cancer and has improved
the use of prostate-specific antigen (PSA) testing in the early
diagnosis and staging of the cancer.
Demonstrating the Efficacy of Radiation Therapy
Radiation therapy is now the treatment of choice for many men
with both early-stage and even more advanced prostate cancers.
But that wasn't always the case. Before Dr. Malcolm Bagshaw's
pioneering work, prostate cancer was considered by many to be
a radioresistant tumor.
Dr. Bagshaw and collaborators at Stanford University showed that
high-dose, small-field radiation could allow selected patients
to undergo potentially curative therapy without the need for surgery.
Moreover, radiation therapy was associated with an extremely low
incidence of urinary incontinence and the preservation of sexual
potency in over 50% of patients treated. This is especially important
since the incidence of prostate cancer rises with age, and many
elderly men have coexisting medical problems that may make surgery
"We have done the largest single series, 1,400 patients treated
with external beam radiation for prostate cancer, some were in
their 40s but others were in their 80s when treated," says
Dr. Bagshaw. "In the early stages of the disease, we showed
that radiation provides a high likelihood of tumor control and
the same life expectancy as a man who doesn't have prostate cancer.
This is true regardless of the age of the patient."
His work also resulted in replacement of cobalt-60 megavoltage
therapy with the linear accelerator for the treatment of locally
advanced cancer. Other innovations by Dr. Bagshaw include the
development of techniques to identify and shield the rectum, anal
canal and sphincter, small bowel, and pubic bone, as well as uninvolved
portions of the urethra, from radiation. "Radiotherapy techniques
for localized prostate cancer devised by Dr. Bagshaw have become
an important standard of care throughout the country," remarked
Joseph G. Fortner, md, President of the General Motors Cancer
In the era before PSA testing was able to detect prostate cancer
in its earliest stages, Dr. Bagshaw carried out a number of important
studies to refine radiation treatment. One series of studies "mapped"
the spread of prostate cancer to the lymph nodes, showing a progressive
spread from the nodes nearest to the gland to the para-aortic
nodes, and led to modification of the radiation field to include
all of the potentially affected nodes. Other studies defined the
role of preoperative testing and exploratory laparotomy for patients
with apparent localized disease. His work has also helped define
the natural history of prostate cancer.
Lifetimes of Achievement
Drs. Bagshaw and Walsh have each published over 100 papers and
numerous book chapters on prostate cancer, as well as edited several
Dr. Walsh is the author of The Prostate: A Guide for Men and
the Women who Love Them (Johns Hopkins Press, 1995), aimed
at the lay public. He earned both his undergraduate (1960) and
medical degrees (1964) from Case Western Reserve University in
Cleveland, Ohio. Dr. Walsh joined the Johns Hopkins faculty in
1974 as Chairman of Urology. His first paper on impotence following
radical prostatectomy was published in 1982.
Dr. Bagshaw's first major study on the role of radiotherapy in
prostate cancer was published in 1965. He received his undergraduate
degree from Wesleyan University in Middletown, Connecticut and
his md from Yale University School of Medicine in 1950. Dr. Bagshaw
joined the Stanford University faculty in 1956, where he became
the first Henry S. Kaplan and Harry Lebeson Professor in Cancer
Biology in 1992.